Office of International Programs
International Activity Health Information Form
The purpose of this form is to enable the Office of International Programs to best assist you should the need arise while you are
studying abroad. Mild physical or psychological disorders may become more serious under the stress of life in an unfamiliar
environment. The pressures of living and /or studying abroad are considerable. Physical and emotional problems can be exacerbated
by local conditions (pollution, new pollens, climate, etc.), the stress of cultural adjustment, local differences in medical practices
available overseas and changes in your diet and exercise routine. Additionally, the system of US health care may not be replicated in
the host country.
This is a voluntary disclosure form and the information you provide will be reviewed by the Office of International Programs and may
be released to your study abroad program in order to try to arrange reasonable accommodations, continuing care, or other
arrangements you have requested. The information provided will be shared only with program staff and faculty on a “need to know”
basis. In addition, this information will be released to appropriate health professionals when health conditions so warrant.
Informed Consent: I understand that I am solely responsible to disclose my health conditions and I take responsibility for the
consequences of not following CDC or program immunization, vaccination or prophylaxis requirements. I understand this
information will be reviewed by the Office of International Programs and may be released to my study abroad program provider or
leader in order to try to arrange reasonable accommodations, continuing care, or other arrangements that I have requested. The
information provided will be shared only with program staff and faculty on a “need to know” basis. I grant permission to use this
information when health conditions so warrant.
Name of Student
UPS ID
Name of Program and Location
Semester Abroad (Fall, Spring or Summer)
Signature
Date
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No
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1.
Are you generally in good physical condition? Yes
If no, please explain:
2.
Please list any allergies that you have (including hay fever/environmental allergies, asthma, &/or food allergies):
*** Include the type of reaction you have to the allergy
Allergy
Reaction
Treatment
3.
Do you have a documented disability, visible or invisible such as a learning disability or any other condition that might
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require special accommodations? Yes No
If yes, please setup an appointment with the study abroad office to assure appropriate accommodations are in place on
site. It is easier to make arrangements in advance than once you are on site.
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4.
No
Have you ever been, or are you currently, being treated for an emotional or psychological problem? Yes
(If “yes”, a note from your counselor or physician is required).
If yes, please indicate the type of health care that you would like us to attempt to locate at your program site:
5.
Please list any serious illnesses, operations or injuries that you feel could affect your health while abroad:
Date
6.
Outcome
Please list any medications that you are currently taking (include the dosage, generic name and condition the medication
was prescribed for). This information will be made available to health care professionals overseas in the event of a medical
emergency. *Please note that in other countries it is not possible to fill prescriptions written in the U.S. In addition, it is not
legal to mail medications from the U.S. to other countries. It is your responsibility to contact a medical professional to verify
that the medication you are taking is legal in your host country, as well as countries where you plan to travel.
Medication
7.
Incident
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Dosage
Condition
Is there any additional health information that we should know about before you study abroad? Yes
If yes, please explain:
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No
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If there are any changes to this information between now and the time of your departure, it is your responsibility to notify the
Office of International Programs with updated information.